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Ohio Department of Public SafetyDivision of Emergency Medical Services

STATE OF OHIO NFPA 1403 BURN PLAN

BURN BUILDING LIVE FIRE EVOLUTIONSPRE-BURN PLAN*

FIRE CHARTER

FIRE CHARTER #

CHARTER ADDRESS

CHARTER PHONE #

PROGRAM DIRECTOR

PROGRAM DIRECTOR PHONE #

1403 BURN BUILDING

BUILDING ADDRESS

DATE OF LAST INSPECTION

AHJ

EMERGENCY PHONE #

*Required for compliance with NFPA 1403, Standard on Live Fire Training Evolutions.

BLANK PRE-BURN PLANS WILL NOT BE ACCEPTED

EMS 1287 3/21 [760-0983]

LIVE BURN DOCUMENT CHECKLIST

SHALL BE ON FILE NO CHANGE SINCE FILING

Burn building maintenance records

Burn building inspection records

Burn building engineering report to include floor plans

EPA Permit

Site plan that meets NFPA 1403

Site planning & equipment needs assessment checklist

Inclement weather SOG

Heat stress index chart - wind chill chart

Water Supply Needs

Live burn fuel package matrix

Instructor/support staff responsibilities

Written learning objectives for all evolutions w/diagrams

Emergency plan for Fire/Police/EMS

Emergency evacuation notification policy

DATE BURN PLAN FILED

PROGRAM DIRECTOR SIGNATURE

XPROGRAM DIRECTOR NAME (Printed)

Please submit this completed form with course request.

If changes have occurred, please include only those pages with course request.

EMS 1287 3/21 [760-0983]1

SITE PLAN THAT MEETS NFPA 1403 (Example)

# LOCATION # LOCATION

1 Burn Building 6 Staging

2 Restrooms 7 Roof Simulator

3 Drafting Pit 8 Storage

4 Rehab/Medical 9 Classroom

5 Storage 10 Incident Command

EMS 1287 3/21 [760-0983]2

1st Floor

EMS 1287 3/21 [760-0983]3

2nd Floor

EMS 1287 3/21 [760-0983]4

SITE PLAN THAT MEETS NFPA 1403 (Example)

1403 BURN BUILDING

BUILDING ADDRESS

DATE OF LIVE BURN

PRIMARY ENGINE

E162BACKUP ENGINE

E161ADDITIONAL APPARATUS

L23, M591

EMS 1287 3/21 [760-0983]5

COLD WEATHER WINDCHILL ASSESSMENTDATE

TIME

TEMPERATURE

WINDSPEED

CURRENT WINDCHILL

AHJ MINIMUM TEMPERATURE FOR OPS

AHJ MINIMUM WINDCHILL FOR OPS

YES NO Windchill is above AHJ Policy for Ops?PRINTED NAME

CERTIFICATION #

SIGNATURE DATE

EMS 1287 3/21 [760-0983]6

HOT WEATHER HEAT INDEX ASSESSMENTDATE

TIME

TEMPERATURE

WINDSPEED

CURRENT WINDCHILL

AHJ MAXIMUM TEMPERATURE FOR OPS

AHJ MAXIMUM WINDCHILL FOR OPS

YES NO Heat Index is above AHJ Policy for Ops?PRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]7

INCLEMENT WEATHER GUIDELINE (Example)

The Instructor-in-charge shall have an awareness of weather conditions, wind velocity, and wind direction. They shall also do a final check for possible changes in weather conditions during burn time.The Instructor-in-charge and the Safety Officer shall always use discretion, common sense and the guidelines presented to make decisions for your safety and the safety of others. The Live Burn Instructor-in-charge, or the Safety Officer shall be responsible for implementing the appropriate actions

Inclement weather defined Rain, hail, sleet, excessive snow, sustained high winds, tornado watch or warning, high heat/stress index (greater than 85 degrees), low wind chill (below 20 degrees)Thunder and/or LighteningIf thunder is heard, or lightening is witnessed by any member, all outdoor training shall immediately cease and all members shall immediately seek indoor shelter. If equipment is laid out, leave it in place and seek shelter immediately. DO NOT use the burn building, forcible entry building, or training tower for shelterBefore outdoor training can resume, 20 minutes must pass without thunder heard and without lightening seenTornado WatchIf a tornado watch is issued, the Live Burn Instructor- in-charge or Safety Officer shall establish some means of communications to stay informed about the changing weather conditionsTornado WarningShould a tornado warning be issued, the designated shelter area shall be the main campus. DO NOT use the burn building, the training tower, or the training building. A PAR shall be conducted by the Instructor-in- charge, or Safety OfficerWindy ConditionsThe Instructor-in-charge or Safety Officer must always be aware of the prevailing wind and establish training scenarios that are not hampered by the wind. Certain training activities will need to be limited if windy conditions present a hazard to the student. Activities such as raising ground ladders, climbing aerial ladders, rope work, and the use of fire props may need to be cancelled or rescheduled. Sustained winds greater than 25 mph or gusty conditions with gusts greater than 25 mph shall be a benchmark for the Instructor-in-charge, or Safety Officer to consider modifying or rescheduling.Heat Stress IndexDetermine the Heat Index then, if applicable: add 10 degrees Fahrenheit for skills requiring the use of structural firefighter personal protective clothing.

Add 10 degrees Fahrenheit for skills conducted in direct sunlight.

If skills are conducted using structural firefighter personal protective clothing and in direct sunlight add 20 degrees Fahrenheit for both PPE and direct sunlight

INSTRUCTORS SHALL ENSURE THAT THE STUDENTS ARE ADEQUATELY HYDRATED AND THAT APPROPRIATE REST PERIODS ARE GIVEN TO ALLOW STUDENTS TO REHAB.

Wind Chill Factor

INSTRUCTORS SHALL ENSURE THAT THE STUDENTS HAVE ADEQUATE REST AND WARMING PERIODS.

ULTIMATELY, THE INSTRUCTOR-IN-CHARGE AND/OR THE SAFETY OFFICER CAN DELAY OR SUSPEND TRAINING.

EMS 1287 3/21 [760-0983]8

SEQUENTIAL LIVE FIRE – BURN MATRIXDATE

TIME

EVOLUTION 1COMPANY ROOM 1 ROOM 2 ROOM 3 ROOM 4

Ignition

Company A

Company B

Company C

Company D EVOLUTION 2

COMPANY ROOM 1 ROOM 2 ROOM 3 ROOM 4Ignition

Company A

Company B

Company C



Company A

Company B

Company C



Company A

Company B

Company C



Company A

Company B

Company C

Company D

EMS 1287 3/21 [760-0983]9

WATER SUPPLY NEEDS (Example)LEVEL OF 25% 50% 75% 100%

Estimated Fire Flow Exposure #1 Fire Flow Exposure #2 Fire Flow Exposure #3 Fire Flow Exposure #4 Fire Flow

Total Required Fire Flow

Required Reserve Flow (50%)

Total On Scene Engine Rated Pump Capacity (Shall Exceed Fire Flow)

NFA Fire Flow: Length x Width ÷ 3 x (# of Floors Involved) = 100% GPM

Required Exposure Fire Flow: 25% of base flow

EXAMPLE: 60’x 20’÷ 3 x 2 (floors) = 800 GPM (100%)

EXAMPLE: Exposure #1 Fire Flow: 200 GPM (25% of total base flow)

PRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]10

INSTRUCTOR ROLES & RESPONSIBILITIES (Example)

Instructor-In-Charge (I.I.C.)1) Has overall responsibility of live fire training.2) Reviews and approves training plans.3) Monitor training activities to ensure safe practices and organizational SOP & SOG’s are followed.4) Conducts post burn evaluation of training staff and operations.5) Identifies and implements any opportunities to improve safety and burn operations.6) Communicates all concerns and safety violations to supervisor.

Lead Instructor (L.I.)

1) Plan and coordinate all required training activities.2) Monitor activities to ensure safe practices and organizational SOP & SOG’s are followed.3) Inspect building integrity prior to and after each Live Fire Training Evolution.4) Assign Staff & Radio:

a. Overall Safety Officerb. Lead Company Instructorsc. Company Safety Officersd. Ignition Officere. Fire Supportf. Pump/Accountability Officerg. Medical Surveillance/Rehab Officerh. Logisticsi. Radio Channel (when applicable)

5) Brief instructors & safeties on responsibilities:a. Accounting for assigned studentsb. Assessing student performancec. Monitoring Student PPEd. Monitoring operational safety.e. Achieving tactical and training objectives (Pre Burn Plan/outline).

6) Follows and monitors the Sequential Burn Plan.

Overall Safety Officer

1) Prevent unsafe acts.2) Eliminate unsafe conditions.3) Intervene and terminate unsafe acts.4) Supervise company safety officers.5) Responsible for the safety of all participants, visitors and spectators.6) Monitor activities to ensure safe practices and organizational SOP & SOG’s are followed.7) Monitor building conditions and training area.8) Monitor interior conditions by communicating with Company Safety Officers and Company Instructors after

company evolutions.9) Monitor Medical Surveillance and Rehab Officer Observations and findings.10) Inspect building integrity prior to and after each Live Fire Training offering.11) Ensure compliance of participant’s personal protective equipment with applicable standards.12) Ensure no more than nine (9) people are in structure during a Live Fire Training Evolution.13) Follows and monitors the Sequential Burn Plan.14) Ensure that all participants are accounted for, both before and after each live fire training evolution.15) Responsible for completing injury reports.

EMS 1287 3/21 [760-0983]11

INSTRUCTOR ROLES & RESPONSIBILITIES (Example)

Company Instructor1) Monitor and supervise assigned students (no more than five students) per Lead Instructor.2) Prevent unsafe acts.3) Intervene and terminate unsafe acts.4) Ensure compliance of participant’s personal protective equipment with applicable standards.5) Evaluate student performance against expected outcomes and recognized job performance requirements6) Account for assigned students, both before and after each Live Fire Training Evolution.7) Be alert to hazardous conditions and report them to the Overall Safety Officer.

Pump Officer

1) Establishes water supply for training.2) Responsible for emergency withdraw signal.3) Monitors pump pressure and engine.4) Personnel Accountability

Ignition & R.I.T. Officer

1) Establishes fire sets based on Live Fire Training Plan & SOP.2) Supervise Fire Support/R.I.T. staff.3) Coordinate fire attack with fueling operations4) Coordinates R.I.T. response during an emergency5) Follows the Sequential Burn Plan.6) Monitors Fire Support staff’s wellness.

Fire Support/R.I.T. Team

1) Constructs fire sets based on Live Fire Training Plan & SOP.2) Provides support role as back-up line.3) Monitors and maintains adequate training fires.4) Acts as R.I.T. Team in an emergency.5) Follows the Sequential Burn Plan.

EMS 1287 3/21 [760-0983]12

EVOLUTION – 1 (Example)LOCATION DATE

TIME

Evolution 1Instructions Entry on level 1 B side Garage advance Hose to the Living room for fire control.

Learning Objectives1. EXAMPLE: Fire behavior and growth2. EXAMPLE: Hoseline advancement3. EXAMPLE: Fog vs. Straight

EMS 1287 3/21 [760-0983]13

EVOLUTION – 2 (Example)LOCATION DATE

TIME

Evolution 2Instructions Entry on level 2 D side advance Hose around Hall to the storage room for fire control.

Learning Objectives1. EXAMPLE: Fire behavior and growth2. EXAMPLE: Hoseline advancement3. EXAMPLE: Fog vs. Straight

EMS 1287 3/21 [760-0983]14

EMERGENCY PLANSLOCATION ADDRESS

CITY

STATE

ZIP CODE

PERSONNEL / AGENCY EMERGENCY # OR CELL #AHJ

Law Enforcement

Fire Department

EMS

IC for Charter

Lead Instructor

Program Director

Total Cadets and Staff# OF CADETS

# OF STAFF

EMERGENCY PLAN - FIREACTIONS COMPLETED

Sound Evacuation Signal

Radio Announcement

Activate RIT

Deploy Back-Up Lines

Notify AHJ Dispatch and request appropriate Assignment

Conduct PAR

Request Additional Resources as needed

EMERGENCY PLAN - EMSACTIONS COMPLETED

Notify On-Site EMS

Notify AHJ Dispatch and request appropriate Response

Conduct PAR

Request Additional Resources as needed

EMERGENCY PLAN - POLICEACTIONS COMPLETED

Notify Location of Active Event

Lockdown or Evacuate

Notify AHJ Dispatch and request appropriate Response

EMS 1287 3/21 [760-0983]15

SHALL BE COMPLETED DAY OF LIVE BURN & KEPT IN COURSE FILE

Conducted Before Live Burn & Reviewed in Pre Burn BriefingACTIONS COMPLETED

Cadet prerequisites met

Instructor List w/Certifications

Review heat stress/wind chill chart for compliance

Incident command organizational chart

Communications plan

Medical plan

Instructor/support staff/cadet assignments

Instructor to cadet ratio (SHALL MAINTAIN 5:1 MIN.)

SCBA & gear inspection

Go/No Go Checklist

CONDUCTED DURING LIVE BURNACTIONS COMPLETED

Rest and rehab for each evolution w/vital sign monitoring

Evolution checklist

Evolution log

REVIEWED AND PREPARED BYPRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]16

CADET TRAINING VERIFICATIONPrior to being permitted to participate in live fire training evolutions, the Cadet shall have received training to meet the minimum job performance requirements for Fire Fighter I of the NFPA 1001, Standard for Fire Fighter Professional Qualifications, related to the following subjects:

1. Safety 2. Fire behavior 3. Portable extinguishers

4. PPE 5. Ladders 6. Fire Hose, appliances & streams

7. Overhaul 8. Water supply 9. Ventilation

10. Forcible entry 11. Forcible entry Course #

I verify that the Cadets in the above listed course are physically fit and have met the education requirements stated above. I also do hereby authorize the individuals to participate in this training session.PRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

FIRE INSTRUCTORS / LIVE BURN INSTRUCTORS / ASSISTANT FIRE INSTRUCTORSInclude all staff that will be assisting in the instruction and testing of the Cadets. Ensure that the ratio of Cadets to instructors does not exceed five to one during all practical skills instruction or evaluation.

Instructors/Support Staff

Name Assignment Cert. Level

Cert.Number

VerifiedDate

Initials

TOTAL NUMBER OF INSTRUCTORS

TOTAL NUMBER OF CADETS

CADET TO INSTRUCTOR RATIO :

I affirm, with my signature, that each instructor holds a current and valid fire instructor certificate, instructors are employed or contracted by the chartered program and instructors are teaching courses at or below the level of an instructor's fire training certificate.PRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]17

INCIDENT COMMAND ORGANIZATIONAL CHARTLOCATION DATE

TIME


CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]18

COMMUNICATION PLAN

PERSONNEL / AGENCY RADIO CHANNEL ASSIGNED COMMENTS

Instructor-in-Charge, IC, Safety

Fire Control Team to Instructor-in-Charge

Burn Instructors to Instructor-in-Charge

Ignition Team

RIT

Cadets

Support Staff

Security

Fire Department

EMS

Law Enforcement

Air Medical

Power Company

Water Company

Natural Gas Company

MEDICAL PLAN

On-Scene EMS (REQUIRED FOR ALL LIVE BURNS)Agency

Level of Care

Transport Capabilities

Location

Emergency #

Emergency Radio Channel

CLOSEST HOSPITALHospital

Location

Estimated Transport Time

Emergency #

EMS 1287 3/21 [760-0983]19

CADET / COMPANY ASSIGNMENT LOGLEAD INSTRUCTOR

TIME

PRIMARY CHANNEL

SUPPORT CHANNEL

A COMPANYROLE NAME CERT. or ID # NOTES

Instructor

Cadet

Cadet

Cadet SAFETY OFFICERS

Cadet 1.

Cadet 2.

B COMPANYROLE NAME CERT. or ID # NOTES

Instructor

Cadet

Cadet


Cadet 1.

Cadet 2.

C COMPANYROLE NAME CERT. or ID # NOTES

Instructor

Cadet

Cadet


Cadet 1.

Cadet 2.

D COMPANYROLE NAME CERT. or ID # NOTES

Instructor

Cadet

Cadet


Cadet 1.

Cadet 2.

EMS 1287 3/21 [760-0983]20

INSTRUCTOR / SUPPORT STAFF ASSIGNMENT LOGLEAD INSTRUCTOR

TIME

PRIMARY CHANNEL

SUPPORT CHANNEL

EMERGENCY RADIO

EVACUATION SIGNAL

Airhorn Blast – 60 Seconds

ASSIGMENTSROLE NAME CERT. LEVEL NOTES

Instructor-in-Charge (IC)

Overall Safety (SO)

Ignition Officer

Ignition Support 1

Ignition Support 2

Ignition Support 3

Rehab Officer

Pump Operator-Primary

Pump Operator - Backup

Medical Officer

Medical Support

Logistic:

Other RAPID INTERVENTION TEAM

In-Charge (IC)

Instructor

Instructor A COMPANY

Instructor

Safety Officer B COMPANY

Instructor

Safety Officer C COMPANY

Instructor

Safety Officer D COMPANY

Instructor

Safety Officer

EMS 1287 3/21 [760-0983]21

PPE / SCBA INSPECTION – INSTRUCTORSINSTRUCTORS CONDUCTING INSPECTIONS CERTIFICATION #

1.

2.

3.

# INSTRUCTOR NAMES

ID / U

nit #

Coat

Pants

Boots

Gloves

Hood

Helm

et

SCB

A

Facepiece

Air B

ottle

PASS

Radio

Flashlight

Eye Pro

Initials

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

I verify that the above gear has passed inspection and is approved for live fire training in accordance with NFPA 1403.PRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]22

PPE / SCBA INSPECTION – CADETSINSTRUCTORS CONDUCTING INSPECTIONS CERTIFICATION #

1.

2.

3.

# CADET NAMES

ID / U

nit #

Coat

Pants

Boots

Gloves

Hood

Helm

et

SCB

A

Facepiece

Air B

ottle

PASS

Radio

Flashlight

Eye Pro

Initials

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

I verify that the above gear has passed inspection and is approved for live fire training in accordance with NFPA 1403.PRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]23

GO / NO-GO CHECKLIST

Complete Before Each EvolutionNAME

DATE

WEATHER / TEMP

/ TIME

GO / NO-GO Checklist COMPLETED

Burn-Plan Review Completed

Safety Officer

Medical Officer

Pump Operator

Accountability Officer

Ignition Officer

Logistics

A Company

B Company

C Company

D Company

Attack Lines / Back-up Lines Flowed

Check Nozzle Pattern

Radio Check

EMS In-Service

GO / NO-GO Checklist COMPLETEDBurn-Plan Review Completed

Safety Officer

Medical Officer

Pump Operator

Accountability Officer

Ignition Officer

Logistics

A Company

B Company

C Company

D Company

Attack Lines / Back-up Lines Flowed

Check Nozzle Pattern

Radio Check

EMS In-Service

EMS 1287 3/21 [760-0983]24

REHAB LOG - INSTRUCTORS (Example)Rehab Location

Rehab Officer

Access to bathroom or portable toilet. Fresh drinking water and cups.Meal for each person at the drill. Sitting area with adequate chairs.Towels/baby wipes for decon/hand sanitizer. Temperature appropriate: cooling fans/heaters.Waste container.

INSTRUCTOR ID #Base Line Evolution #1

Time Temp. H.R. R.R. B.P. Pulse Ox. Time Temp. H.R. R.R. B.P. Pulse

Ox.

*Please Refer to NFPA 1584 for Rehab Guidelines*

EMS 1287 3/21 [760-0983]25

REHAB LOG - CADETS (Example)Rehab Location

Rehab Officer

Access to bathroom or portable toilet. Fresh drinking water and cups.Meal for each person at the drill. Sitting area with adequate chairs.Towels/baby wipes for decon/hand sanitizer. Temperature appropriate: cooling fans/heaters.Waste container.

Cadet ID #Base Line Evolution #1

Time Temp. H.R. R.R. B.P. Pulse Ox. Time Temp. H.R. R.R. B.P. Pulse

Ox.

*Please Refer to NFPA 1584 for Rehab Guidelines*

EMS 1287 3/21 [760-0983]26

EVOLUTION CHECKLIST

Complete During Each EvolutionSTART TIME

END TIME

DATE

Evolution Checklist #1 #2 #3 #4

Full PPE w/SCBA (No Exposed Skin)

Maintain Accountability

Check Nozzle before entry

All team members have a tool

TIC

Victim in place (No live victims during live fire training)

Search Pattern Completed

Victim Located

Victim Removed

Building properly ventilated

Company properly communicated with Command

Conduct PAR per SOG and at completion of evolution

Temperatures monitored

EMS 1287 3/21 [760-0983]27

EVOLUTION LOGDATE

TIME

EVOLUTION 1

Company Time In Time Out

Temperature MonitoringHall Stairs Door Floor Ceiling Door Floor Ceiling

Alpha

Bravo

Charlie

Delta

EVOLUTION 2



Alpha

Bravo

Charlie

Delta

EVOLUTION 3



Alpha

Bravo

Charlie

Delta

EVOLUTION 4



Alpha

Bravo

Charlie

Delta

EVOLUTION 5



Alpha

Bravo

Charlie

Delta

EMS 1287 3/21 [760-0983]28

SHALL BE COMPLETED AFTER LIVE BURN & KEPT IN COURSE FILE COMPLETED

AAR (After Action Review)

Cadet/Instructor Discharge Instructions

Instructor List w/Certification #’s (Updated if Needed)

YES NO SHALL BE COMPLETED AS NEEDED & KEPT IN COURSE FILE Date Initials

First Report of Injury (DEMS Notified)

First Report of Un-Safe Act (DEMS Notified)

COMMENTS


CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]29

CRITIQUE / AAR (After Action Review)DATE

TIME

INSTRUCTORS/STAFF RECOMMENDATIONS

Priority Item LeadInitials Implemented

CADET RECOMMENDATIONS

Priority Item LeadInitials Implemented


CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]30

CADET / INSTRUCTOR DISCHARGE INSTRUCTIONS

Review ChecklistWash hands and face before eating and drinking Drink a minimum of 16 oz. of waterShower ASAP to wash off carcinogens Change your clothesLaunder your clothes separately Eat a nutritious mealWash PPE including helmet, hoods and gloves Consume 32 oz. or more of water throughout eveningAll injuries shall be reported to Program Director within 24 hrs.

16 FIREFIGHTER LIFE SAFETY INITIATIVES

THE NATIONAL FALLEN FIREFIGHTERS FOUNDATION’S EVERYONE GOES HOME® PROGRAM1. Define and advocate the need for a cultural change within the fire service relating to safety;

incorporating leadership, management, supervision, accountability and personal responsibility.

2. Enhance personal & organizational accountability for health & safety in the fire service3. Focus greater attention on the integration of risk management with incident management at all

levels, including strategic, tactical, and planning responsibilities.4. All firefighters must be empowered to stop unsafe practices.5. Develop and implement national standards for training, qualifications, and certification (including

regular recertification) that are equally applicable to all firefighters based on the duties they are expected to perform.

6. Develop and implement national medical and physical fitness standards that are equally applicable to all firefighters, based on the duties they are expected to perform.

7. Create a national research agenda and data collection system that relates to the initiatives.8. Utilize available technology wherever it can produce higher levels of health and safety.9. Thoroughly investigate all firefighter fatalities, injuries, and near misses.10. Grant programs should support the implementation of safe practices and/or mandate safe

practices as an eligibility requirement.11. National standards for emergency response policies and procedures should be developed and

championed.12. National protocols for response to violent incidents should be developed and championed.13. Firefighters and their families must have access to counseling and psychological support.14. Public education must receive more resources and be championed as a critical fire and life

safety program.15. Advocacy must be strengthened for the enforcement of codes and the installation of home fire

sprinklers.16. Safety must be a primary consideration in the design of apparatus and equipment.

EMS 1287 3/21 [760-0983]31

FIRST REPORT OF INJURYName: Phone #:

Age: Gender:

Injury Date: Injury Time:

Injury Location: City/State/Zip:

Nature of Injury: EMS Agency:

Transport Facility: Injured Status:

Course: Course #:

Witness: Witness Cell:

Injury Details1. What task was the injured person performing?

2. How was the person injured?

3. Factors contributing to the injury?

4. Were there any unsafe acts leading to the injury, if so please describe?

5. Did any equipment or apparatus fail? Please describe any equipment or apparatus failures.

6. What steps should be taken to prevent similar injuries?

7. Was injury immediately reported? If no, please explain.

Injury Report Narrative

PRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]32

FIRST REPORT OF UNSAFE ACTName Phone #

Age Cadet or Staff

Event Date Event Time

Event Location City/State/Zip

Nature of Event Injuries

Course Course #

Incident Details1. What task was the cadet/instructor person performing?

2. What was the unsafe act?

3. How was the cadet/instructor being supervised?

4. Was any equipment and/or apparatus being used?

5. What steps should be taken to prevent similar unsafe acts?

6. Was the unsafe act immediately reported? If no, please explain.

7. Would this incident have resulted in an injury? If yes, please explain.

Incident Narrative

PRINTED NAME

CERTIFICATION #

SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]33

Ohio Department of Public SafetyDivision of Emergency Medical Services

APPENDIX AACQUIRED STRUCTURELIVE FIRE EVOLUTIONS

PRE-BURN PLAN*

*Required for compliance with NFPA 1403, Standard on Live Fire Training Evolutions

BLANK PRE-BURN PLANS WILL NOT BE ACCEPTED

EMS 1287 3/21 [760-0983]34

ACQUIRED STRUCTURE CHECKLISTBuilding Address:

Building Description:

Initial Fire Assignment:

Unique Hazards Present:

Lead Instructor: Instructor Cell:

AHJ: AHJ Chief:

AHJ Emergency #: Non-Emergency #:

Property Owner: Owner Cell:

Property Manager: Management Cell:

Occupancy Type: Construction Type:

Roof Construction: Floor Construction:

Number of Floors: Total Square Foot:

Year Built: Basement:

Hydrant Location #1: Available Flow:

Hydrant Location #2: Available Flow:

YES NO ACTION DATE INITIALS

Proof of Clear Title

Proof of insurance cancellation

Fire Department Liability Insurance Coverage

Local/Regional Law Enforcement Notice

Notice to Adjacent Property Owners

Utility Notification: Gas, Electric, Water

EPA Permit

Asbestos Inspection

Asbestos Mitigation

Acquired Structure Preparation Checklist

Owners release to damage and/or burn structure

Acknowledgment of Building use & Post burn condition

Completion of Burn transfer to AHJ

Transfer of authority back to property owner

Site plan that meets NFPA 1403

Site planning & equipment needs assessment checklist

COMMENTS

DATE BURN PLAN FILED

PROGRAM DIRECTOR SIGNATURE

X*Please submit pages 35-45 with course request.

EMS 1287 3/21 [760-0983]35

ACQUIRED STRUCTURE PLAN - PROOF OF CLEAR TITLEBuilding Address:

EMS 1287 3/21 [760-0983]36

ACQUIRED STRUCTURE PLAN - PROOF OF INSURANCE CANCELLATIONBuilding Address:

EMS 1287 3/21 [760-0983]37

ACQUIRED STRUCTURE PLAN - FIRE DEPARTMENT LIABILITY INSURANCE COVERAGEBuilding Address:

Most political subdivisions and their fire departments have liability insurance which covers any acts or omissions that may take place during a structural burn.

Fire department members are covered under the Workers Compensation plan obtained by the political subdivision to which the fire department belongs.

If this training is not being conducted through a state education institution, such as the Minnesota State Colleges and Universities institution, remember to obtain liability insurance to cover the unexpected problems that may come up. This should include exposure and medical, plus anything else you might be concerned about.

CITY/TOWNSHIP LIABILITY INSURANCE OBTAINED: Yes No

DOCUMENTATION ENCLOSED: Yes No

Fire Chief:

Fire Department:

Date:

EMS 1287 3/21 [760-0983]38

ACQUIRED STRUCTURE PLAN – ASBESTOS INSPECTION / MITIGATIONBuilding Address:

EMS 1287 3/21 [760-0983]39

ACQUIRED STRUCTURE PLAN – EPA PERMITBuilding Address:

EPA Permit #: Permit Dates:

EPA Inspector: Inspector Phone:

EMS 1287 3/21 [760-0983]40

ACQUIRED STRUCTURE PLAN – OWNERS RELEASE TO DAMAGE OR BURN STRUCTUREBuilding Address:

Legal Description:

City: County:

Building Official: BO Phone:

Having agreed with the building official, City or

County of , that a structure owned by

and located at the following address:

County of , Township of ,

In the City of with Nearest Cross Road of .

Is under condemnation or unfit for human habitation and is beyond rehabilitation. I further agree that the structure

should be used by the fire service for training as they see fit. In order that demolition may be accomplished, I give

my consent to the City/Township of to use or demolish the

said structure by burning or other means.

OWNER SIGNATURE

XDATE

OWNER SIGNATURE

XDATE

BUILDING OFFICIAL SIGNATURE

XDATE

EMS 1287 3/21 [760-0983]41

TRAINING SITE LOCATION - EXAMPLEFull Building Address: 1007 Mountain Drive, Gotham City, Ohio

EMS 1287 3/21 [760-0983]42

ACQUIRED STRUCTURE 1ST FLOOR PLANS - EXAMPLE

EMS 1287 3/21 [760-0983]43

ACQUIRED STRUCTURE 2nd FLOOR PLANS - EXAMPLE

EMS 1287 3/21 [760-0983]44

ACQUIRED STRUCTURE SITE PLANS - EXAMPLEBuilding Address:

Dates of Live Burn:

Primary Engine: E162 Backup Engine: E161

Additional Apparatus: L23, M591

EMS 1287 3/21 [760-0983]45

ohio emergency medical servicesems.ohio.gov/links/ems1287.docx · web viewdivision of emergency...

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